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The Toronto General Hospital Transitional Pain

Service: development and implementation of a
multidisciplinary program to prevent chronic
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postsurgical pain
This article was published in the following Dove Press journal:
Journal of Pain Research
12 October 2015
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Joel Katz 1–3 Abstract: Chronic postsurgical pain (CPSP), an often unanticipated result of necessary and
Aliza Weinrib 1,2 even life-saving procedures, develops in 5–10% of patients one-year after major surgery. Sub-
Samantha R Fashler 2
For personal use only.

Rita Katznelzon 1,3 stantial advances have been made in identifying patients at elevated risk of developing CPSP
Bansi R Shah 1 based on perioperative pain, opioid use, and negative affect, including depression, anxiety, pain
Salima SJ Ladak 1
catastrophizing, and posttraumatic stress disorder-like symptoms. The Transitional Pain Service
Jiao Jiang 1
Qing Li 1 (TPS) at Toronto General Hospital (TGH) is the first to comprehensively address the problem
Kayla McMillan 1 of CPSP at three stages: 1) preoperatively, 2) postoperatively in hospital, and 3) postoperatively
Daniel Santa Mina 5,6
Kirsten Wentlandt 4,7
in an outpatient setting for up to 6 months after surgery. Patients at high risk for CPSP are
Karen McRae 1,3 identified early and offered coordinated and comprehensive care by the multidisciplinary team
Diana Tamir 1,3 consisting of pain physicians, advanced practice nurses, psychologists, and physiotherapists.
Sheldon Lyn 1,3
Marc de Perrot 8 Access to expert intervention through the Transitional Pain Service bypasses typically long
Vivek Rao 9 wait times for surgical patients to be referred and seen in chronic pain clinics. This affords the
David Grant 10
opportunity to impact patients’ pain trajectories, preventing the transition from acute to chronic
Graham Roche-Nagle 11
Sean P Cleary 12 pain, and reducing suffering, disability, and health care costs. In this report, we describe the
Stefan OP Hofer 13 workings of the Transitional Pain Service at Toronto General Hospital, including the clinical
Ralph Gilbert 14
algorithm used to identify patients, and clinical services offered to patients as they transition
Duminda Wijeysundera 1,3
Paul Ritvo 15 through the stages of surgical recovery. We describe the role of the psychological treatment,
Tahir Janmohamed 16 which draws on innovations in Acceptance and Commitment Therapy that allow for brief and
Gerald O’Leary 1,3
Hance Clarke 1,3
effective behavioral interventions to be applied transdiagnostically and preventatively. Finally,
1
Department of Anesthesia and Pain Management, we describe our vision for future growth.
Toronto General Hospital, University Health Network,
University of Toronto, 2Department of Psychology, York Keywords: Transitional Pain Service, chronic postsurgical pain, transition to chronic pain,
University, 3Department of Anesthesia, University of
Toronto, 4Palliative Care, University Health Network, opioid use, multidisciplinary treatment
University of Toronto, 5Princess Margaret Cancer
Centre, University Health Network, University of
Toronto, 6Faculty of Kinesiology and Physical Education,
University of Toronto, 7Department of Family and
Community Medicine, University of Toronto, 8Division
Introduction
of Thoracic Surgery, Toronto General Hospital,
9
Division of Cardiovascular Surgery, Toronto General
Chronic pain is the silent epidemic of our times.1 The economic costs of chronic pain in
Hospital, 10Multiorgan Transplant Program, Toronto
General Hospital, 11Division of Vascular Surgery,
the US are estimated to exceed the costs of heart disease, cancer and diabetes.2 Chronic
Toronto General Hospital, 12Division of General
Surgery, Toronto General Hospital, 13Division of
postsurgical pain (CPSP) is a significant driver of this cost, with annual direct and indirect
Plastic Surgery, Toronto General Hospital, 14Division
of Otolaryngology – Head and Neck Surgery, Toronto
per patient estimates of US$41,000.3 Given that the one-year incidence of moderate-
General Hospital, 15Department of Kinesiology and
Health Science, York University, 16ManagingLife, Toronto,
to-severe CPSP is between 5% and 10%, and that world-wide, more than 230 million
ON, Canada people undergo major surgery every year, the global annual cost of new cases of CPSP
is in the hundreds of billions of dollars.6 Equally concerning is the humanitarian cost
Correspondence: Joel Katz; Hance Clarke of CPSP, which is all too frequently the unanticipated result of necessary and even life-
Pain Research Unit, Department of Anesthesia and Pain
Management, Toronto General Hospital, 200 Elizabeth St., 3 saving surgery. CPSP deprives the individual of vital energy and productivity and leads
EB-317, Toronto, ON, M5G 2C4, Canada
Email jkatz@yorku.ca; hance.clarke@uhn.ca to many negative secondary, downstream effects.7

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License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further
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 Katz et al Dovepress

The response to this costly tragedy has been unaccept- p­ roduce substantial savings, shorter hospital stays, earlier
ably slow.4 For more than 20 years, we have made progress weaning from opioid analgesic medications, reduced emo-
in managing acute postsurgical pain through new insights tional distress, improved quality of life, and reduced inci-
and novel findings in pre-emptive/preventive analgesia.4,8,9 In dence and severity of CPSP and disability. Preliminary data
contrast, breakthroughs have not been made in minimizing already support some of these anticipated outcomes.10,11
the transition to CPSP. In order to accomplish this goal, we
need a multidisciplinary preventive approach that involves Risk factors for CPSP
intensive, perioperative psychological, medical, physical Over the past several years, substantial advances have been
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therapy, and pharmacological management interventions made in identifying risk factors for CPSP4,5,12–19 (Figure 1).
aimed at preventing and treating the factors that increase the Our data and that from other published literature clearly show
risk of CPSP and associated disability.4,10,11 the following factors reliably predict CPSP across a range
In this paper, we briefly review the main risk factors of surgical procedures: perioperative pain (the presence and
for CPSP and then describe a novel multidisciplinary pain intensity of preoperative pain, high intensity acute postopera-
program, the Transitional Pain Service (TPS), which we have tive pain),20–25 perioperative opioid use,20,26 preoperative nega-
developed and implemented over the past year (since 2014). tive affective states including posttraumatic stress disorder
The TPS is designed specifically to identify patients at risk (PTSD)-like symptoms,27 depression,28,29 anxiety,18,28,30–32 and
of CPSP, to intervene in a tailored and timely way medi- pain catastrophizing.12,17,32,33 The known psychological risk
cally, psychologically, and with complementary treatments factors for CPSP (negative affect, catastrophizing) are also
For personal use only.

to minimize the transition to chronicity, and to reduce reli- risk factors for intense, acute postoperative pain and high/
ance on opioid medications by focusing on treatment across excessive use of opioid analgesics in the acute postoperative
the hospital-to-home trajectory. We anticipate the TPS will setting.34,35 Inadequately controlled acute pain and excessive

Preoperative Intraoperative Post-operative

Acute Long-term

Catastrophizing Poor QoL Pericostal

stitches
Pain
State
anxiety Low volume
surgical unit Posttraumatic
Robustness
stress symptoms
Depression Pain Analgesics
Optimism

Pain
Psychosocial Pain
disability
Surgical
Physical
function
Duration Psychosocial
Neuro-
psychological

Catastrophizing
Biological
“Open” Nerve
Rey-osterrieth approach damage
�
complex figure Social
� Stair test support

Inflammation Solicitous
Trails-B
�
� Lower extremity responses
Younger age Female
difficulty

Pre-emptive/preventive analgesia

COX-2 Alpha-2
SNRIs Opioids Acetaminophen
inhibitors agonists

Alpha-2-delta Local NMDA

NSAIDs
ligands anesthetics antagonists
Time

Figure 1 Schematic illustration of the processes involved in the development of chronic postsurgical pain and pain disability showing relationships among preoperative,
intraoperative, and postoperative risk/protective factors. Copyright © 2009 Katz and Seltzer. Adapted with permission from Katz J, Seltzer Z. Transition from acute to chronic
postsurgical pain: risk factors and protective factors. Expert Rev Neurother. 2009;9(5): 723–744.3
Abbreviations: QoL, quality of life; SNRIs, serotonin–norepinephrine reuptake inhibitors; NSAIDs, nonsteroidal anti-inflammatory drugs; NMDA, N-Methyl-D-aspartic acid.

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 Dovepress Transitional Pain Service to prevent chronic postsurgical pain

analgesic use have been repeatedly shown to delay recov- Table 1 Table of surgical procedures for patients enrolled in the
ery and hospital discharge following many surgeries.36–40 Transitional Pain Service
Moreover, high pain intensity,41,42 negative affect,41,43 and Type of surgery Specific surgeries

catastrophizing41,44 are all risk factors for opioid misuse/abuse Cancer-related surgeries
 Thoracic Lobectomy
in patients with chronic pain. Our own data show that 3%
Pneumonectomy
of previously opioid-naïve patients continue to use opioids Wedge resection (lung)
90 days after major elective surgery.45 The TPS is designed to Video-assisted thoracic surgery (VATS)
target and manage these known risks pre- and postsurgery in   Gastrointestinal Esophagectomy
Whipple
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an effort to reduce pain, disability, and opioid misuse, while Liver resection
also benefitting the health care system by facilitating earlier Bowel resection
discharge and reducing costs. Bile duct reconstruction
Cholecystectomy
Colostomy
Overview of the TPS Ileostomy
The mission of the TPS is the treatment of patients who are Gastrectomy
at risk for transitioning from acute to CPSP. As such, it is the   Gynecologic oncology Total abdominal hysterectomy (with or
without bilateral salpingo-oophorectomy
first service to comprehensively address the problem of CPSP
and/or omentectomy)
after major surgery through multidisciplinary, coordinated   Urologic Nephrectomy
care beginning preoperatively, extending postoperatively, Radical prostatectomy
For personal use only.

and continuing into the posthospital discharge period once Cystectomy

  Head and neck Mandibulotomy
patients have returned home. The three primary goals of Maxillectomy
the TPS are to: 1) provide a novel, seamless approach to Glossectomy
pre- and postoperative pain management for patients who Laryngectomy
Tracheostomy
are at increased risk for developing CPSP and pain disabil-
  Breast cancer Total mastectomy (with deep inferior
ity, 2) manage opioid medication for medically complex epigastric artery perforator flap)
patients post-discharge, and 3) improve patient coping and Modified radical mastectomy
functioning in order to ensure as high a quality of life as Radical mastectomy
Breast reconstruction surgery
possible after surgery.
Cardiac surgeries Coronary artery bypass graft (CABG)
Minimally invasive direct coronary artery
Institutional setting bypass (MIDCAB)
The TPS is situated at Toronto General Hospital (TGH), part Heart valve surgery
Angioplasty
of the University Health Network, in Toronto, ON, Canada. Vascular surgeries Amputations (toe, below the knee,
TGH is Canada’s leading surgical center, specializing in above the knee)
surgical oncology, cardiac surgery, vascular surgery, and Axillary–femoral bypass
Femoro–femoral bypass
multiorgan transplantation, with more than 6,000 surgeries
Aortobifemoral bypass
performed annually. TPS patients have undergone a vari- Femoropopliteal bypass
ety of surgical procedures (Table 1) including procedures Aortic aneurysm repair
such as thoracotomy, mastectomy, and limb amputation, Multiorgan transplant Kidney transplant
Kidney–pancreas transplant
after which as many as one in two patients may develop
Lung transplant
CPSP.4,46 Liver transplant
Heart transplant
TPS staff Surgery for living donors (liver and
kidney)
Presently, the TPS comprises five anesthesiologists with
advanced training in acute and/or chronic interventional pain
management, two clinical psychologists and trainees, three Patient flow during the pre-
acute pain nurse practitioners, two physical therapists with and intraoperative periods
expertise in acupuncture, a palliative care specialist/family Patients are identified as candidates for the TPS as early
physician, an exercise physiologist, a patient-care coordina- as the surgical preadmission visit, when a comprehensive
tor, and an administrative assistant. medical assessment is performed, covering key areas such

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 Katz et al
as preexisting conditions, current medications, and special
considerations for anesthesia. At this time, approximately
12.5% of patients are identified with a “pain alert” due to
chronic pain problems requiring daily opioid medication. This
“pain alert” is attached to their chart for the duration of their
surgical admission. These patients are assessed after surgery
by the TPS, with particular attention to their needs as “acute-
on-chronic” pain patients with high opioid requirements.
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For a subset of highly complex patients, a multidisci-
plinary perioperative pain management plan is created prior
to surgery; for example, a personalized pain management
plan was created for a patient who was awaiting lung trans-
plant in hospital, due to his complex clinical picture, includ-
ing chronic degenerative lung disease, chronic back pain with
high daily opioid use, a history of misuse of street drugs,
as well as depression and anxiety. After assessment by the
TPS, his opioid medication was reduced in preparation for
transplant by adding opioid-sparing multimodal medication
For personal use only.
and his pain intensity decreased.
Patients who are not identified prior to surgery by screen-
ing in the preadmission clinic or by their surgical team can be
referred to the TPS after surgery by the Acute Pain Service
(APS) or by their surgical team. The APS refers patients to
TPS if they have intense or prolonged postsurgical pain, high
opioid use, notable emotional distress, or the need for ongoing
expert pain management consultation and care (see Table 2
Table 2 Transitional Pain Service (TPS) referral criteria
•  Preoperative chronic pain with or without opioid use
• Intense postoperative pain.
  ○ Prolonged Acute Pain Service (APS) stay based on surgical
intervention
  ○ Patients with intense pain, who continue to be seen by the APS
beyond the expected trajectory
  ○ Patients requiring a repeat APS consultation once discharged from
the APS (initiated by the surgical team)
  ○ Medically stable patients unable to be discharged due to a complex
pain problem
•  High postoperative opioid consumption
  ○ Patients who consume more than 90 mg/day of oral morphine
equivalents given high requirement for opioid weaning assistance
after discharge
  ○ Patients admitted on methadone or buprenorphine who do not
have access to a community pain specialist
  ○ Patients discharged with a prescription for a long acting opioid-
based medication
  ○ Patients needing interventional postsurgical procedures (eg, stump
catheters post-amputation)
• Emotional distress
  ○ Depression, anxiety, pain catastrophizing, or other psychosocial
concern identified by APS or TPS screening questionnaires
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for further details). TPS nurse practitioners begin in-hospital
optimization of multimodal analgesia and enhanced teaching
for the patient and their family. Patient education may include
a review of the analgesics, guidance on better utilization of
these analgesics and management of side effects, as well the
importance of preventive analgesia in order to reduce pain
upon movement and allow patients to participate more effec-
tively in postoperative rehabilitation regimens. Next, one of
the TPS pain physicians reviews the patient’s chart, assesses
the patient (both in person and through a standardized self-
report assessment battery), and develops a multidisciplinary
pain plan tailored to the patient’s needs. This pain plan may
include a referral to a TPS psychologist or physiotherapist,
as appropriate, who then begins a personalized intervention
while the patient is in hospital. Patients are followed by TPS
with continued optimization of analgesic medication and
involvement of the multidisciplinary team until hospital
discharge. A key goal of this intensive team treatment is to
reduce pain and distress as well as delayed discharge due to
uncontrolled pain.
Postoperative period
Once patients are medically fit for discharge, they are booked
for follow-up appointments at the TPS outpatient clinic, also
located at TGH. Patients receive a follow-up telephone call
from the TPS team coordinator within 3 days of hospital
discharge. In clinic, follow-up visits generally occur 2 to
3 weeks after discharge, but can take place within days for
patients who need urgent care.
At the initial visit to the outpatient TPS clinic after sur-
gery, patient progress is assessed and a detailed discussion
is had with the patient (and the patient’s family, if present)
regarding the pain treatment plan and the process of weaning
from opioid medications. The patient is assessed for opioid
addiction risk and an opioid agreement contract is signed
prior to opioid prescribing. The clinical psychologist is
involved with patients who are high-dose opioid users, who
have a history of chronic pain or mental health problems,
and/or those who report significant current distress and pain
(assessed from a standardized set of psychological tools
used at intake). Patients are also offered physiotherapy and/
or acupuncture to help restore function and relieve pain. The
primary care physicians and surgeons receive a summary
of all clinic visits. Patients are assessed once every 2 to 3
weeks and their opioid medications and other analgesics
are adjusted until they are at a safe level, their pain is under
control, and their daily function approaches their baseline
(presurgical) level. The TPS aims to transition patients back
Journal of Pain Research 2015:8
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to their primary care physicians within 6 weeks to 6 months
of hospital discharge (ie, after 3–6 visits).
The role of the psychological
team within the TPS
Psychological intervention has a critical, widely established
role in the effective multidisciplinary treatment of chronic
pain.47 In contrast, psychological intervention has rarely
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been central in the management of postsurgical pain, despite
consistent findings that psychological factors such as pain
catastrophizing, depression, anxiety, and posttraumatic
symptoms are predictive of CPSP outcomes (such as pain
intensity, pain-related disability, and opioid use).4,48 There is
a growing call for integration of psychological services from
the earliest time point, rather than waiting for CPSP to be
entrenched before such services are offered.49,50
Psychological assessment
For personal use only.
The TPS is guided by our awareness of the psychological
predictors of CPSP from our earliest contact with each
patient. Upon referral to the service (prior to surgery or within
days after surgery), patients complete validated self-report
measures that assess psychological risk factors (such as pain
catastrophizing, depression, and anxiety). In addition, patients
undergo a brief assessment interview by a clinical psycholo-
gist. The goal of the assessment interview is twofold. First,
for patients who are identified as distressed by self-report
measures or by the APS, the interview gathers information on
the nature of the distress (eg, depression, anxiety, PTSD, lim-
ited pain coping repertoire, stressful life circumstances) and
identifies early targets for treatment. Secondly, the interview
serves to screen for risk factors for opioid misuse. To this end,
a brief history is taken of the patient’s presurgical functioning
in relationships and education/employment, prior history of
substance use and misuse, and mental health issues. Psycho-
logical risk factors for opioid misuse or difficult postsurgical
recovery are communicated to the TPS team.
Psychological intervention
The goals of psychological intervention within the TPS
are to 1) assist patients in the development of personalized
pain management plans, 2) address distress and associated
mental health issues that have the potential to amplify pain
and increase opioid use, 3) support opioid weaning with
behavioral pain management skills, and 4) reduce pain-
related disability for patients with persistent pain. These
key areas must be covered in a brief behavioral intervention
that is acceptable to medical patients who are not seeking
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Transitional Pain Service to prevent chronic postsurgical pain
weekly psychotherapy or other such traditional psychologi-
cal services.
Our primary modality of psychological intervention is a
brief form of Acceptance and Commitment Therapy51 (ACT)
called the ACT Matrix.52 ACT is a type of cognitive behavioral
therapy that incorporates mindfulness, acceptance, and an
emphasis on behavioral choices based on personal values.53
ACT research on chronic pain has gained momentum over the
past 15 years54 and now ACT has been rated as having strong
research support for the treatment of chronic pain, according to
the American Psychological Association, Division 12.55 In addi-
tion, a growing body of research supports the use of brief ACT
workshops for medical patients, including patients with pain
conditions such as migraine.56 Indeed, medical patients who
would not consider psychological treatment – even though they
do have comorbid depression, for example – have reported that
1-day ACT workshops are acceptable and helpful to them.56
We have adapted our brief ACT protocol into a presurgical
workshop delivered in a group format, encompassing both
behavioral intervention and pain psychoeducation. We can
also provide the intervention to patients on a one-on-one basis,
most commonly in a three-session protocol delivered after sur-
gery. The psychological intervention covers many key areas,
including identifying personal functioning goals, observing
and describing pain and the thoughts and feelings that come
with pain, identifying avoidance behaviors and analyzing
when they exacerbate pain, distress, and dysfunction, and
noticing the impact on pain of engaging in valued activities
in a paced manner. A strength of this protocol is that it can be
applied transdiagnostically to treat acute and/or chronic pain,
depression, anxiety, PTSD, substance misuse, and personality
disorders.52 Our goal is to test our psychological intervention
in a randomized controlled trial to better understand its impact,
both short term and long term, on pain intensity, amount of
opioid used, mood, and pain disability.
Moving forward: future
developments for the TPS
Given the successful implementation of the TPS in the past
year (since 2014), we have begun to expand the program in
several ways.
1. We are now accepting referrals for outpatients with mod-
erate to severe postsurgical pain who underwent surgery
at other hospitals.
2. We have reached out to family physicians in the com-
munity to afford their patients an expedited assessment
and intervention process if the patient is within 6 months
of the surgical intervention.
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 Katz et al
3. We will be expanding the TPS to include patients undergo-
ing orthopedic surgical procedures including total knee
and total hip arthroplasties.
4. Based on our research in children and adolescents under-
going major surgery,17,19,57 we have identified the transition
from adolescence to young adulthood as another signifi-
cant gap in transitional pain care and plan to develop a
specialized arm of the TPS to manage these patients.
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5. To enhance the provision of care within the TPS, we are
designing physical fitness programs to prehabilitate and
rehabilitate participants who are known to improve physi-
cal functioning and psychological resilience including
yoga and mindfulness practices.58
6. We have identified as a priority the need to implement a
centralized pharmacy tracking system to monitor opioid
prescriptions and prevent double doctoring.
7. To leverage e-health and mobile technology as a way of
engaging TPS patients once they are discharged and as
For personal use only.
a way of improving the assessment and management of
CPSP. Beyond complementing the existing TPS program,
such technology may improve the accuracy and frequency
of patient-reported pain outcomes, enable remote moni-
toring, provide exception-based alerts, and be a significant
part of the equation for predictive analytics.
Conclusion
Taken together, the current TPS and planned expansions
are designed to address the historical gaps in pain manage-
ment for postsurgical patients. Our goal is to transform the
management of pain in postsurgical patients by provid-
ing seamless care beginning preoperatively, continuing
throughout the hospital stay and after patients return home
post-hospital discharge. Finally, important next steps are to
determine the efficacy of the TPS in preventing CPSP and to
evaluate the extent to which the TPS reduces hospital stay,
hospital readmission rates, and overall costs to the health
care system.
Acknowledgments
Joel Katz is supported by Canadian Institutes of Health
Research Canada Research Chair in Health Psychology at
York University. Hance Clarke is supported by a Merit Award
from the Department of Anesthesia, University of Toronto
and received funding from the Ontario Ministry of Health and
Long Term Care, Medically Complex Patients Demonstration
Project Program for a project entitled “The Transitional Pain
Service Demonstration Project”.
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Disclosure
The authors report no conflicts of interest in this work.
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